Dr. Jorge Gonzales-Martinez, Co-Director, UPMC Comprehensive Epilepsy Center discusses the cutting-edge, individualized treatment available at the center and the advanced surgical techniques used to help treat patients.
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– [Narrator] This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.
– From diagnosis, to state-of-the-art care, offering hope to people with epilepsy. Welcome to the UPMC HealthBeat Podcast. I’m Tonia Caruso, and joining us right now is Dr. Jorge Gonzales-Martinez. He’s the director of the Epilepsy and Movement Division of the UPMC Department of Neurosurgery and the co-director of the UPMC Comprehensive Epilepsy Center. Doctor, thanks so much for joining us.
– My pleasure.
– And so when we talk about the Comprehensive Epilepsy Center, you’re a level 4 center. What exactly does that mean?
– A level 4 center is an epilepsy center that offers all types of treatments for patients with medically tractable or medically intractable epilepsy. So that means patients that will be controlled with medication. And if the patients are not controlled with medication, sometimes surgery is necessary. At the level 4, we can offer all sorts or all types of operations or surgeries that we can offer in order to treat patients with medically intractable epilepsy.
– And so let’s talk about epilepsy, beginning exactly with, what exactly epilepsy is and how it affects the body.
– Epilepsy is a disarrange of electrical activity in the brain. The cells, the neuronal cells, are electrical cells, and they fire in a certain synchronized way. When there is this desynchronization, or this disruption of how the cells fire normally, this will cause what we call seizures. And epilepsy is recurrent seizures, patients that will have seizures over and over and over again.
– And how common is epilepsy?
– Unfortunately, epilepsy is a relatively common disease. It affects approximately 1.5% of the world population. So in the United States, we can predict it at probably, we have approximately 3-4 million people with epilepsy. In the world, were are talking about 65 million people with this disease.
– So, then, let’s give folks a sense of what happens when they come to the UPMC Comprehensive Center for Epilepsy. When a patient comes through the door, what is sort of the process, and talk a little bit about the team that works together.
– You know that you’re offered the best treatment for patients with epilepsy. This is a combined effort from neurology, neuropsychologists, neuroradiologists. So the patient will come to the epilepsy center, and the first approach will be to be seen by a neurologist specialist specialized in epilepsy, an epileptologist. The neurologist, the epileptologist, will evaluate the seizures, the type of seizures. Normally, those patients, they will need to have what we call a scalp EEG, when we can correlate the results of the abnormal brain signals to the semiology, to the type of seizures they’re having. And then from that point, initially, perhaps imaging, MRI images, will be performed. The initial treatment will be medication as I said before. And this patient will be continued to be treated and followed up by our team. If medication fails and we’re talking about two or three medication trials, then this patient may be considered for a surgical intervention. At this point, another meeting will happen: what we call a patient management conference meeting, which is a multidisciplinary meeting which involves the epileptologists, the neurosurgeons, the neuroradiologists, neuropsychologists. And we all together, we review all the data in details to understand why this patient is not being controlled with medication. And if there is any option in terms of surgical treatment. If there is an option in terms of surgical treatment, what type of option is available? And then this patient is referred to an epilepsy surgeon. Once this patient is referred to an epilepsy surgeon, we’ll talk with the patient and discuss the specific procedures that will be necessary for this patient. We’ll talk about the risks and the benefits of this procedure. And then we will schedule surgery for that particular patient. We will follow the patient after surgery, and this patient will be followed by the surgeon and also by the epileptologist who saw him before, or her before. So this is truly a combined multidisciplinary approach that involves all those disciplines.
– And surgery is really your area of expertise. And you’ve actually helped to pioneer some surgical techniques. And talk a little bit about where surgery is today.
– Epilepsy surgery around for a long time, we’re talking about perhaps 150 years of surgeries related to epilepsy. There are the more conventional surgeries, which we call the resections, which will require the removal of the areas in the brain that are causing the seizures. In order for you or for the patients to be a good candidate for epilepsy surgery, we need to have three main aspects. No. 1, we need to make sure that the patient is what we consider to be medically intractable. That’s the reason why we talked before that this patient needs to be seen by an epileptologist, and this patient needs to be treated correctly with medication. If those patients after two or three trials of medication cannot be controlled, then we consider to be this patient medically intractable and potentially a candidate for surgery. That is criteria No. 1. The criteria No. 2 is that in order for surgeons, for us to be able to treat patients with epilepsy, we need to know exactly where the seizures are coming from. So we need to make sure that the seizures are coming from a focal area in the brain, so we can go there and remove that area. In order to be sure that we know exactly from where the seizure coming from, that’s the reason why we have the patient management conference discussion, when we put all the data together: the type of seizures, the scalp EEG, the MRI, and all the images in neuropsychology. And then together, we make a hypothesis. Perhaps the seizures are coming from this area, or for sure the seizures are coming from this area. So that’s the second criteria. The third criteria is to make sure that that area that we are going to treat, is an area that does not hold an important function in the brain. If this is an area that controls motor, speech, vision, language, perhaps other types of treatments can be offered. Many times, if the localization is not clear, perhaps an additional surgery is necessary. And this additional surgery is in order to better localize from where the seizures are coming from, so we can perform the focal resection. This is what we call invasive monitoring. And this invasive monitoring can be performed through what we call subdural grids, which requires a craniotomy, or through a less invasive or minimally invasive procedure, which is the placement of depth electrodes through little tiny pinholes, something that we call stereotactic EEG. Stereotactic EEG was something that we brought to the country many years ago and is associated with a better localization of seizures, especially in deep areas and also with less morbidity in the localization. So once we localize the seizures, again after we perform the SEG, after we place the electrodes, we can go ahead and do the resection that we mentioned before.
– And the advantage of these less invasive surgeries — talk about the impact that can have on recovery time and overall success of a surgery for a patient.
– Methods of less invasive — for example, the stereo EEG — is associated with less morbidity, less complications, shorter length of stay in the hospital, less pain, and again, less complications. The electrodes are placed in various particular areas in the brain, so we can truly pinpoint the smallest areas that are responsible for your seizures. So the surgeon can perform the smallest resection necessary. Because we don’t require craniotomy, also complications are much less because there is no big openings on the skull. We can do everything through little tiny holes that has probably around maybe two or three millimeters in diameter. So truly a minimally invasive approach. So minimal pain, less length of stay, and better localization. Those are the advantages of methods like the SEEG.
– And I know that safe counseling is a key component. And can we tell folks briefly what that is?
– So safely consulting is to make sure that we understand that the advantages of performing the procedure overcast or are superior to the risks related to the procedure. So if we believe the patient has severe seizures that are medically intractable, and we believe that the method to localize the seizures are less invasive, minimally invasive, then is when the patient becomes a very good candidate for those types of procedures. If the seizure burden is small and the risks are high, so perhaps this patient will not be a good candidate for this type of procedure. So that’s the reason why to offer less invasive procedures, it makes a lot of sense. Because patients with severe epilepsy now can be treated with much less complications that we used to have before.
– Doctor, how has COVID-19 impacted care? Did you have to stop seeing patients? Are you continuing to see patients? Let’s talk a little bit about that.
– So epilepsy is a very diverse disease, and there are patients with very mild seizures and patients with very severe seizures. So at this point, because of the COVID, patients with less severe seizures are being treated by telemedicine, so we can avoid direct contact with them in the clinic. However, we consider that severe epilepsy is a life-threatening situation. So that’s the reason why we continue to treat our patients that we judge that they need to be treated sooner than later. And in that point, the procedures are being done, of course, with a lot of precautious in the OR with protections, masks, but continue pretty much the same procedures that we used to do before COVID-19. Again, it’s an evaluation of how severe are the seizures, and we’ll treat you accordingly.
– Well, doctor, some really good information. Thank you so much for coming in and spending time with us today. We appreciate it.
– You’re very welcome. It’s a pleasure to be here.
– I’m Tonia Caruso. Thank you for joining us. We’ll see you next time on UPMC HealthBeat.